Browse 6,488 coroners' Regulation 28 reports by year, region, and keyword. Data sourced from judiciary.uk.
Contains public sector information licensed under the Open Government Licence v3.0.
AI-generated concerns summaryThe coroner highlighted the ineffectiveness of product recalls for items installed by a third party in domestic properties, noting the absence of a requirement for professional purchasers to track end users or inform manufacturers.
Addressed to: Department for Business, Energy and Industrial Strategy
AI-generated concerns summaryThe coroner noted the accumulation of standing water at the collision scene unless effectively drained, and identified a gap in the vehicle restraint barrier as a hazard to traffic.
Addressed to: Highways England
AI-generated concerns summaryThe coroner identified an illogical discharge decision despite mental health deterioration, an absence of pre-discharge meetings with the GP, and no policy for urgent GP referrals. Difficulties for the family to communicate concerns were also noted.
Addressed to: Cricket Green Medical Practice; Department of Health and Social Care; St George’s Mental NHS Trust
AI-generated concerns summaryThe coroner noted an under-recognition of the seriousness of jaundice in children beyond the neonatal period by medical professionals, highlighting that non-escalation to specialists can adversely affect care and be life-threatening, particularly where urgent referral for transplantation is needed.
Addressed to: Royal College of Emergency Medicine; Royal College of Paediatrics and Child Health
AI-generated concerns summaryThe coroner noted a lack of fluid balance charting and monitoring of urine output, alongside no written handover regarding changes in condition. Concerns were also raised about staff training and understanding of male catheterisation and long-term catheter care.
Addressed to: ABMU Health Board; Tynant Nursing Home
AI-generated concerns summaryThe coroner noted the absence of monitored beds on surgical wards at Salford Royal Foundation Trust, where a review is underway to explore their potential to save lives.
Addressed to: Salford Royal Foundation Trust
AI-generated concerns summaryThe coroner recommended Devon Highways consider installing "no through road" signs at the start of the road and reflective warning signs on the wall at its closed end to prevent similar incidents.
Addressed to: Highways Infrastructure Development and Waste
AI-generated concerns summaryThe coroner noted inconsistencies in bed rail risk assessments between hospital sites and contradictory responses within one hospital's assessment forms. Concerns were raised that the decision not to use bed rails did not sufficiently account for the patient's immobility, paralysis, and involuntary movements.
Addressed to: Great Western Hospitals NHS Trust
AI-generated concerns summaryThe coroner noted insufficient training for Emirates staff in cardiac arrest recognition and CPR, and inadequate procedures when remote medical assistance systems fail. Concerns also related to ambulance trusts consistently missing national response time targets and limited paramedic staffing at Manchester Airport.
Addressed to: Department of Health and Social Care; DLA Piper Solicitors; Emirates Airlines; Manchester Airport Group; North West Ambulance Service
AI-generated concerns summaryThe coroner noted a lack of appropriate signage warning of water risks in the Roker Harbour area, particularly concerning the use of inflatable devices, and a lack of lifeguard supervision.
Addressed to: Sunderland City Council
AI-generated concerns summaryThe coroner identified inadequate and delayed allergy care plans for pupils, ineffective communication between the school and caterer, and an unsafe allergy identification system. Crucially, the Local Authority did not communicate safety recommendations to the school.
Addressed to: Al Hijrah School; Birmingham City Council; Birmingham Community Healthcare NHS Trust; Caterlink
AI-generated concerns summaryThe coroner identified a lack of urgency in securing a mental health bed for a seriously ill patient and noted inadequate assessment by the mental health nurse before discharge. Concerns included insufficient team consultation and unclear follow-through on post-discharge referrals.
Addressed to: Camden and Islington NHS Trust; Royal Free London NHS Trust
AI-generated concerns summaryThe report identified that dumper truck safety procedures were not consistently followed, not accessible to all personnel, and lacked audit. Additionally, there was no established process or industry standard for safe spoil heap management.
Addressed to: Health and Safety Executive; Tonic Construction Ltd
AI-generated concerns summaryThe coroner noted that night shift staff did not consider a head injury as the cause of the deceased's confusion and lacked training to identify or exclude head injuries in residents, which could impact future diagnoses.
Addressed to: Abbotsbury Elderly Persons Home
AI-generated concerns summaryThe coroner noted that the resident may not have been aware his call-bell was portable or able to move it due to mobility issues, and the care home had not considered introducing wearable call bells.
Addressed to: Hillbrook Grange Residential Care Home
AI-generated concerns summaryThe coroner identified a lack of risk assessment for the East Wing ward's multi-floor layout and insufficient formal guidance on observation competency for agency staff. Further concerns included a lack of clear policy for classifying and investigating ligature incidents as Serious Untoward Incidents.
Addressed to: MENTAL HEALTH NATIONAL PROGRAMMES OF CARE BOARD, NATIONAL HEA; Care Quality Commission; NHS; Priory Hospital Roehampton
AI-generated concerns summaryThe coroner noted an inadequate system for determining and monitoring grip levels on London's cycle superhighways and other roads, highlighting the need for urgent research into scientific methods for grip assessment and the effects of varying grip values.
Addressed to: TFL
AI-generated concerns summaryThe coroner identified that landlords in Wales are not under a legal duty to install working smoke alarms in rented properties, contrasting with the legal requirements in England.
Addressed to: Welsh Assembly Government
AI-generated concerns summaryConcerns were raised regarding inadequate warning signage and restricted visibility of a crossroads junction due to high hedgerows. Previously recommended modifications by Capita, which were not implemented, should be reconsidered to minimise future incident risks.
Addressed to: Cumbria County Council
AI-generated concerns summaryThe coroner noted a lack of long-term mental health care provision for children in Leicestershire who cannot attend hospital due to anxiety, as the existing CRISIS team is not equipped for this function.
Addressed to: East Leicestershire and Rutland Clinical Commissioning Group; Secretary of State for Health